Sunday, January 21, 2018

Dementia Advance Directive?

I read a recent article in the New York Times as part of the New Old Age Series. Paula Span writes  One Day Your Mind May Fade. At Least You’ll Have a Plan. The article is about advance directives for those with dementia as discussed in a recent article published in the Journal of the American Medical Association (JAMA).  The idea of the dementia-specific advance directive is to express your wishes based on the specific "phase" of dementia you may enter in the future.  The website for this directive is here from which the 5-page directive may be downloaded.  The NY Times article describes the directive "In simple language, it maps out the effects of mild, moderate and severe dementia, and asks patients to specify which medical interventions they would want — and not want — at each phase of the illness."

In the JAMA article, the authors make the case that other existing advance directives aren't particularly helpful for those with dementia because of the way it progresses over time with corresponding diminishing cognitive function (a subscription is required to access the article).  The NY Times article notes that "[a]lthough [dementia] is a terminal disease, dementia often intensifies slowly, over many years. The point at which dementia patients can no longer direct their own care isn’t predictable or obvious. ... Moreover, patients’ goals and preferences might well change over time. In the early stage, life may remain enjoyable and rewarding despite memory problems or difficulties with daily tasks."

The dementia-specific directive describes the person's wishes  as "goals of care" and offers four options for each stage of dementia, directing the person to "[s]elect one of the 4 main goals of care listed below to express your wishes. Choose the goal of care that describes what you would want at this stage."  The directive divides dementia into three stages, mild, moderate and severe.

There are already a number of types of advance directives, with recent pushes for POLST and other initiatives such as the Conversation Project.   Then there is the Five Wishes document,  which as been around for a number of years. Attorneys may be incorporating dementia-specific instructions into advance directives already.

Interesting.

 

January 21, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, January 19, 2018

Intergenerational Shared Housing

We have previously blogged about the concept of shared housing. It can take many forms and can be a great option for certain elders.  The New York Times ran an article about it in NY. Getting a Roommate in Your Golden Years explains that

The concept of pairing older people with younger ones, particularly those who are not family members, is not a new one: It was popularized by Maggie Khun, an elder-rights activist who opened up her Philadelphia home to others for more than 20 years before she died in 1995. Today’s home sharing, however, is as likely to be between those of the same age as it is to be intergenerational. The crucial thing is that it involves two or more people sharing an apartment or a house to their mutual benefit. And finances often play a big role.

The article focuses on the win-win, cost savings on both sides among others. The article features one New Yorker who is running low on funds and turned to a service in Manhattan that matches folks. "The New York Foundation for Senior Citizens connected her with a licensed social worker who asked a host of questions, including details about her sleeping habits, personality, interests and daily schedule. She also had to provide three personal recommendations and her rental agreement, to prove she was on the lease. And she was asked to describe what she considered the ideal roommate. Her response: someone who wasn’t home much."

Another expert quoted in the story notes that shared housing can be a way to fight homelessness amongst elders. Don't think homelessness is an issue for elders? Think again. "Statistics show that the number of older Americans who are homeless is growing. In 2007, homeless people 62 and older who sought shelter accounted for 2.9 percent of the country’s homeless population. By 2016, the percentage had risen to 4.7, according to estimates from the National Alliance to End Homelessness, a Washington, D.C., advocacy group."

Does an elder need to go through an organization to find a roommate? No, but there are certainly advantages to doing so! For example, one elder interviewed for the story detailed her travails in finding the right match. Another expert in the article highlighted the benefits of using an agency.

She advises those interested in home sharing not to go about it on their own: Go through a nonprofit service, she said, or ask a trusted eldercare professional, friends or family to help properly vet the prospective roommates. And before you sign a lease with a boarder, make sure to do a background check... “You need a huge amount of trust and to be very clear with your expectations,” she said. . . “But if you have the help you need to stay in your home — and the tenant gains affordable housing in exchange — I think there’s much to gain socially and spiritually when young and old live together.”

 

January 19, 2018 in Consumer Information, Current Affairs, Housing, Other | Permalink

UPitt Law Prof Larry Frolik Urges Change in Pennsylvania Guardianship Law to Clarify Lawyer's Role in Representing Alleged Incapacitated Persons

Larry Frolik, University of Pittsburgh Law Professor and all-round elder law guru, responds to a 2016 decision by the Pennsylvania Superior Court for In re Sabatino with a strong call for change in existing guardianship laws.  In the abstract for his January 2018 article for the Pennsylvania Bar Association Quarterly on The Role of Counsel for an Alleged Incapacitated Person in Pennsylvania Guardianship Proceedings [currently membership-restricted], he writes:  

When a petition is filed requesting that court find an individual to be incapacitated and appoint a guardian for the individual, the alleged incapacitated person [AIP] has a right to counsel. If the individual does not have counsel, the court may, but is not required to,  appoint counsel. Whether counsel is hired by the [AIP] or appointed by the court, the question arises as to what is the proper role of counsel.  Should counsel act solely as a zealous advocate and attempt to resist the imposition of the guardianship if so directed by the [AIP] or should counsel act in the best interest of the person with counsel making the determination of what is in the person's best interest?

 

A 2016 Superior Court case considered that issue and concluded that if the [AIP] desired not to have a guardian, counsel should so inform the court, but counsel, acting in what counsel believed was the person's best interest, could also tell the court that counsel believed that the person needed a guardian.  That holding is not consistent with the fundamental obligation of counsel to advocate for what the client, the [AIP], desires.  Counsel should not be making an independent determination that the person would be better served if a guardian were to be appointed.  The decisions as to whether an [AIP] is legally incapacitated and, if so, whether the appointment of a guardian is appropriate, are decisions that only a court should make.  

 

The Pennsylvania Legislature should amend the law of guardianship to clarify that the role of counsel for an [AIP] is that of a zealous advocate, and that counsel should not act in what counsel believes are the person's best interest.  If the Legislature does not act, in the future courts should reexamine the issue and rule that counsel should act solely as a zealous advocate and not attempt to promote the person's best interest. 

January 19, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Legal Practice/Practice Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Thursday, January 18, 2018

Patient Dumping-By the Health Care Provider

There's been a lot of buzz after that video surfaced of a hospital patient left at a bus stop just in a hospital gown. NPR ran a follow up story, Why Was A Baltimore Patient Discharged At A Bus Stop In Just A Gown?  The president and CEO of the hospital in a subsequent press conference indicated that the event was isolated and those involved would answer for their actions.  There is a lot we don't know about the story (and some we may never know because of privacy issues). CBS then ran a story from the mother of the patient. In the story Mother calls hospital "callous and heartless" for leaving her daughter in the cold, the mother explains that her daughter, the patient, has mental illness.

How is this different, if at all, than granny dumping, where a family member might abandon an elder relative at the emergency room? I did a quick google search to see if I turned up any recent articles on granny dumping, and didn't really find much, except for this one from a year ago, Japanese people who can't afford elder care are reviving a practice known as 'granny dumping'.

What's your take? Is this not specifically happening much, if at all, in the US any more?

 

January 18, 2018 in Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink

Stunning Rate Increases Likely to Continue for Owners of Long-Care Insurance Policies

The Wall Street Journal has an update article this week on the financial  health of the long-term care insurance industry, detailing recent rate increases and reminding us that even with contraction of this specialized market for sellers of new policies, there are still more than 7 million policies affected by the inadequate pricing structure issues.  

Steep rate increases that many policyholders never saw coming are confronting them with an awful choice: Come up with the money to pay more—or walk away from their coverage.

 

“Never in our wildest imagination did we consider that the company would double the premium,” says Sally Wylie, 67, a retired learning specialist who lives on Vinalhaven Island, Maine.

 

In the past two years, CNA FinancialCorp. has increased the annual long-term-care insurance bill for Ms. Wylie and her husband by more than 90% to $4,831. They bought the policies in 2008, which promise future benefits of as much as $268,275 per person. The Wylies are bracing for more increases.

Even with the rate increases, companies are looking at losses in anticipation of claims as existing policy holders are now aging into a claims mode. General Electronic Company, has attempted to reassure shareholders about the impact of its LTCI business on profits.  

Only a dozen or so insurers still sell the coverage, down from more than 100. General ElectricCo. said Tuesday it would take a pretax charge of $9.5 billion, mostly because of long-term-care policies sold in the 1980s and 1990s. Since 2007, other companies have taken $10.5 billion in pretax earnings charges to boost reserves for future claims, according to analysts at investment bank Evercore ISI. . . . 

 

Almost every insurer in the business badly underestimated how many claims would be filed and how long people would draw payments before dying. People are living and keeping their policies much longer than expected. After the financial crisis hit, nine years of ultralow interest rates also left insurers with far lower investment returns than they needed to pay those claims.

 

Long-term-care insurers barreled into the business even though their actuaries didn’t have a long record of data to draw on when setting prices. Looking back now, some executives say marketing policies on a “level premium” basis also left insurers with a disastrously slim margin of error.

 

“We never should have done it, and the regulators never should have allowed it,” Thomas McInerney, president and chief executive ofGenworth FinancialInc. since 2013, says of the pricing strategy. “That’s crazy.”

For more of this detailed article, see  Millions Brought Insurance to Cover Retirement Health Costs.  Now They Face an Awful Choice.  Our thanks to University of Illinois Law Professor Dick Kaplan and New York attorney Karen Miller for bringing this article to our attention.  

 

January 18, 2018 in Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Property Management, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Wednesday, January 17, 2018

What Does it Mean to Have a "Perfect Score" on a Cognitive Assessment Test?

I've sat in on dozens of mental acuity screening exams for individuals exhibiting indications of some form of dementia.  

Regarding the "perfect score" reportedly received by President Donald Trump on a mental acuity screening test during his January health exam, it may be helpful to consider what is -- and isn't -- covered by such assessments.  One view is provided in an opinion piece this week in the Washington Post, using history from a criminal case where Brooke Astor's son and an attorney were found guilty of exploiting her alleged mental incapacity.    From the article: 

On its surface, the Montreal Cognitive Assessment (MoCA) test seems pretty easy. Can you draw a three-dimensional cube? Can you identify these various animals? Can you draw a clock? Can you repeat back the phrase, “The cat always hid under the couch when dogs were in the room”? . . . 

 

If you look at the test, it’s pretty hard to see how you could not score a 30. You see a picture of a lion and have to identify it as a lion? That old joke about how the elderly and toddlers are subject to the same indignities seems pertinent here: Is this really the bar that needs to be met to demonstrate full mental capabilities?

 

Well, according to those who study dementia and other mental deterioration, yes.

 

In 2009, I spent six months serving on a jury in the state of New York that was asked to judge the guilt or innocence of a man named Anthony Marshall. Marshall was the son of Brooke Astor, a New York socialite and heiress to the much-diminished Astor fortune. If you’ve ever traveled to New York, you’ve encountered the name: Astor Place, the Waldorf-Astoria or the Astoria neighborhood in Queens. Marshall was accused of having taken advantage of Astor’s diminished mental state to change her will without her being aware of the changes made. Ultimately, the 12 members of the jury found Marshall guilty of several charges.

 

Over the course of that trial, we were presented with a great deal of information about how doctors assess the mental capabilities of a patient. This was critical to the prosecution; were they not able to prove that Astor’s mental state was diminished, it undercut their argument that Marshall had acted without his mother’s consent. As such, expert witnesses testified about their personal examinations of Astor and others spoke to the reliability of the tests.

 

Central to that case was one of the components of the MoCA test: drawing a clock. Astor was asked repeatedly to draw analog clocks as a test of her mental acuity. On more than one occasion, she was unable to do so properly. . . . 

 

The point is not that the test is easy. The point is that an inability to complete aspects of the test reveals different types of mental decline. The clock test is about executive brain function: memory, planning ahead. The different parts of the MoCA are labeled according to what they test, with the clock test falling under “visuospatial/executive.” Questions about the current year and date are under “orientation.” The request to identify a drawing of a camel is under “naming.” In the test’s scoring instructions, it explains what is covered: “attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations and orientation.”

 

It is, as Trump’s doctor noted, a tool for identifying early signs of mental deterioration, like the mental version of a blood sample on which your doctor runs a battery of tests. It’s not the SAT; it’s a screening device.

For more, read Why You May Be Misunderstanding the Mental Test that Trump Passed with Flying Colors, by Philip Bump.

January 17, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Science | Permalink | Comments (0)

FINRA FAQ for Elder Financial Exploitation

FINRA has released FAQs specifically to address elder financial exploitation. Frequently Asked Questions Regarding FINRA Rules Relating to Financial Exploitation of Seniors  explains the new rules that take effect on February 5, 2018.  "[T]he SEC approved: (1) the adoption of new FINRA Rule 2165 (Financial Exploitation of Specified Adults) to permit members to place temporary holds on disbursements of funds or securities from the accounts of specified customers where there is a reasonable belief of financial exploitation of these customers; and (2) amendments to FINRA Rule 4512 (Customer Account Information) to require members to make reasonable efforts to obtain the name of and contact information for a trusted contact person (“trusted contact”) for a customer’s account."(citations omitted) FAQs 1 and 2 deal with temporary holds, 3 with trusted contacts, and 4 with disclosures.  The FAQ are available here.

January 17, 2018 in Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, Other, Property Management | Permalink

Tuesday, January 16, 2018

Oh Those Boomers: Reaping the Impact of Loud Music

Those Boomers (or should I say, more accurately, we boomers). We invented lots of things (if you ask us) including rock 'n roll and now we are experiencing hearing loss. It was only a matter of time.... after years of playing all that rock music so loudly (of course our parents warned us), we are reaping the after effects-hearing loss (this is a tongue in cheek statement, BTW). Baby boomers destroyed their hearing. Biotech is trying to fix it 

opens with these paragraphs

Baby boomers grew up with music blasting from dorm room turntables, car stereos, and arenas where the sound of a band at full throttle could rival the roar of a jet engine. Volume became an act of generational defiance. As rocker Ted Nugent put it: “If it’s too loud, you’re too old.” ... Turns out, it was too loud. Millions of boomers are now grappling with hearing loss — some of it caused by turning the volume to 11 — prompting companies to develop treatments that improve upon the expensive and often limited-value hearing aids and surgical implants that have been around for decades.

Intrigued. Find yourself amongst those who maybe played your music at "11"?  Want to read more?  The Boston Globe also an the article.  The article looks at the frequency (no pun intended, honestly) of hearing loss and it's a lot, the treatments being researched, and more. And before you go off to tell your children to turn down the volume on their music, the article notes noise isn't the only reason for hearing loss. Some of it is genetic and another is age related. Technology plays a role as well, with one expert noting the impact of leaf blowers and ear buds.  Different devices and developing drugs are being studied as an option for those with hearing loss.

January 16, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, Other, Science | Permalink | Comments (1)

Choice and Customer Service in Senior Living

My sister and I have been interviewing locations for several weeks as possible residential settings for our mother, especially as she is no longer able to handle the stairs in her two-story home, but feels trapped by not being able to choose on her own where to walk.  We know that the best way to approach this task is in small doses, and to do it before there is an emergency that limits choices.  This is actually our second go-round, as we also did this with Mom when we were looking at a place for Dad almost 5  years ago.  But we have been very struck by the changes in the marketplace in just that short period of time:

  1. There are many new options, both large and small, that have come into being in just the last five or fewer years.  We have looked at "classic" versions of continuing care communities, as well as what I would call "ala carte" pricing options for communities that offer a wide range of care alternatives, but each for a separate, escalating price and with no assurances of a placement. We've looked at both modest settings and high end "assisted living centers" that are so new the paint has not quite dried. But most of all, what we have found ourselves focusing on are smaller group homes, licensed under that state's law for "assisted living," and under that law the care includes almost all necessary care, other than certain so-called skilled services (such as catheters, feeding tubes, or I.V. hydration).  We liked the small group setting because they often were in a neighborhood that would make our mother feel at home, while still offering a purposeful renovation that included carefully designed toilets, showers and flooring for easier movement.  The price range is stunningly broad between these options, too.
  2. Doctors are not always the best advisors on choices.  We have found that even though our mother has a wonderful primary care doctor, and even though that doctor makes it known that most of his patients are older, he did not seem to be aware that there are group home options.  He kept telling us we'd need a "skilled care nursing home."  But, as Mom has a pretty detailed end-of-live directive that rejects feeding tubes, and similar skilled care interventions, it seems clear to us that we can look at a well-run facility licensed for assisted living that will be able to provide appropriate care through her last days.  
  3. A lot of the smaller places are accessed through what I would call "brokers."  When you do internet research, the odds are that your first contacts will be with some kind of "finder."  Most of these are paid by the facilities, rather than the families conducting the searches.  As such, there is the clear potential for them to steer families to "their" facility clients.  I know from insiders in the industry that the fees are often the equivalent of one month's fee at the chosen location.  While not necessarily a negative, as a good broker is only successful if he or she really knows the available inventory of residential options, the fees are something that can dramatically impact smaller group homes that are operating on a narrower margin.

Additional trends we noticed? We discovered that a small group home that appears to be a  "family" operation,  may actually be part of a chain of homes with a single corporate owner.  On the other hand, at several of the places we visited, we learned the owner had recently purchased another house in the same neighborhood, and was in the process of a second renovation.  Also, as for staffing, we noticed that in certain parts of the city, all of the caregivers were immigrants from the same country, whether Poland or Pakistan or elsewhere.  Another reminder that realistic immigration policies are a key component to senior living. 

Finally, probably our strongest reaction was to differences in what can only be called old fashioned "customer service."  One "famous," established  CCRC completely lost our interest when the person at the front desk never made direct eye contact with us, instead keeping one hand on a cell phone and the other hand on a very dirty "wet wipe" she said she was using to clean surfaces because it was "flu season." It didn't help that we went through three different people to find one who could give us a tour during a scheduled visit (the first two were so new they didn't have knowledge of the full campus.) At the smaller group homes, we definitely noticed when the persons we met with greeted current residents by name as they gave us a tour.  Also, did they know the names of their own staff members  -- and did they introduce us to each other?  When a trip hazard was lying in wait on the floor, did they pick it up -- or merely avoid it?  

In addition to asking about staffing ratios and open visiting hours, we wanted to know about how long each of the staff members we met had worked at the particular place.   Finally, our whole family likes dogs and therefore it was a plus when we found a place that had a "house dog" that the residents clearly loved, but we recognize that not every place can handle the extra work it takes to maintain a pet on site.  

A sad irony is that it is unlikely our mother will live in the same care setting that was so perfect for our father.  That place is an assisted living center with four cottages, purpose built for Alzheimer's care, on a five acre setting.  But it has become clear to us that even though Mom was the one who chose it for Dad, and it is a wonderful place, with people we still love, our mother probably doesn't want it for herself.  In the last few months of our father's residence there before his death, she visited less and less often, and we came to realize she had "already" rejected it for herself.  It wasn't about memories of Dad; rather, it was about what it meant to "also" have the same cognitive impairment.  The director, who has become a good friend of mine, said that is not unusual -- that even successful residential settings are rarely chosen by families for second or third placements because the next loved one can be hypersensitive to the reality of that choice.  Senior care living -- a tough business in which to generate repeat business. 

January 16, 2018 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Housing, State Statutes/Regulations | Permalink | Comments (1)

Monday, January 15, 2018

Regenerative Medicine: The FDA

Stem Cells!  The New England Journal of Medicine published an article on regenerative medicine. Rejuvenating Regenerative Medicine Regulation explains FDA action regarding the regulation of regenerative medicine.

The Food and Drug Administration (FDA) recently made long-awaited progress toward protecting patients from interventions involving human cell- and tissue-based products (HCT/P) of unknown safety and efficacy. By clarifying its position on the handling and therapeutic use of cells, the agency has sent a clear signal that it intends to regulate a broad swath of highly manipulated cellular materials as biologic drugs. This is a welcome development, and complementary action taken at the state level and by professional societies would further promote the interests of patients.

The question of whether using the patient's own stem cells falls under the FDA or medical practice has been one of debate, which are addressed with the issuance of these guidance documents.  The authors see these as a step in the right direction but not the final step. A pdf of the article is available here.

January 15, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Filial Friday on Monday: PA Supreme Court Agrees to Hear Further Appeal of "Reverse" Filial Support Case

Regular readers of this Blog will remember that we have been following the case of Melmark Inc. v. Schutt, wherein a residential facility for disabled children and adults in Pennsylvania, has sought to hold 70+ year-old New Jersey parents liable for approximately 13 months of care the facility provided for their autistic adult son after New Jersey stopped public payments for his support.  The parents were successful at the trial and intermediate courts of appeal in Pennsylvania, arguing that New Jersey, not Pennsylvania law controlled the issue of any filial obligation.  Pennsylvania statutory law imposes liability on certain family members, without regard to age, to cover costs of care provided to "indigent" children or parents, while New Jersey's filial support statute limits obligations for older adults, for "any person 55 years or over," to support for minor children or spouses.  See N.J.S.A. Section 44:1-140(c) (Relatives Chargeable).   The unpaid costs in question totaled more than $200,000, before the Melmark took it upon itself to take the son back to New Jersey, dropping him off at a local hospital.

On December 26, 2017, the Pennsylvania Supreme Court granted the facility's request for further appeal on the following issues:

1. Whether the Superior Court erred as a matter of law in finding that New Jersey’s filial support statute, rather than Pennsylvania’s, applied
in this matter where there is no conflict between the New Jersey statute and Pennsylvania’s statute under the facts of this case?


2. Whether the Superior Court erred in finding that New Jersey has a greater interest in the application of its filial support statute where, inter alia, all of the relevant contacts, with the exception of the residency of Respondents Clarence and Barbara Schutt, are with Pennsylvania; where the Schutts took affirmative actions to keep their highly disabled son in a Pennsylvania nonprofit residential and therapeutic institution, Petitioner Melmark, Inc., with the avowed aim of Melmark funding his care for his “entire life,” including manipulating the Pennsylvania and New Jersey legal systems to prevent his return to New Jersey; and where the Superior Court’s decision results in Melmark being entirely uncompensated for providing an extended period of vital, intensive care for the Schutts’ son?


3. Whether the Superior Court erred in finding that the lower court properly denied relief on Melmark's claims for quantum meruit and unjust enrichment? 

I've been teaching Conflicts of Law for many years and I actually used a variation on this problem for the final exam in my Fall 2017 course.  As was true in the lower courts in the Melmark case, most of my students came to the conclusion that under the forum's choice of law rules, the state with the most substantial relationship to the issue of parental liability for statutory support was the state where the parents and son were residents, here New Jersey.  

My best guess is that the Pennsylvania Supreme Court may go more deeply into  the common law claims for "quantum meruit and unjust enrichment" (which in Pennsylvania are usually treated as alternative names for the same causes of action, sometimes termed "quasi-contract" claims). 

As I've been saying for months now, this is a tough case for everyone.  

January 15, 2018 in Current Affairs, Ethical Issues, Health Care/Long Term Care, Medicaid, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, January 12, 2018

Federal Right to Try Legislation

The New England Journal of Medicine recently published an opinion article, Federal Right-to-Try Legislation — Threatening the FDA’s Public Health Mission. The second paragraph sets out the issues

[T]he FDA created “expanded access” pathways to give desperate patients without other options access to promising products before approval, while still providing oversight. The agency received more than 5000 requests under those pathways between 2010 and 2014.1 But in August 2017, the Senate passed the Trickett Wendler, Frank Mongiello, Jordan McLinn, and Matthew Bellina Right to Try Act, which would sharply curtail the FDA’s oversight of access to investigational drugs for patients with life-threatening illnesses.2 Though popular with the public and supported by politicians from both parties, the legislation has been widely criticized by policy experts. In isolation, its impact would probably be limited, since the bill was substantially hollowed out to secure the necessary votes. Nonetheless, the motivation behind the proposed legislation threatens to weaken the FDA’s ability to pursue its public health mission.

The article discusses the bill, the concerns expressed and the countervailing arguments.  The authors conclude "[a]re we prepared to abandon the FDA’s gatekeeping role in favor of unfettered patient autonomy and market forces, risking precisely the problems that prompted Congress to grant the FDA its present authority? The agency has made substantial progress in balancing the needs of desperate patients and the principle that all patients deserve evidence that the benefits of medical products justify their risks. We upset that balance, and diminish the FDA’s public health mission, at our peril."

A pdf of the article is available here.

January 12, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care | Permalink | Comments (0)

Thursday, January 11, 2018

ER Visit Signals Underlying Issues?

Kaiser Health News ran a story about how an ER visit may signal underlying, and maybe undiscovered, issues for elders. For Elder Health, Trips To The ER Are Often A Tipping Point explains that "[a]n older person’s trip to the ER often signals a serious health challenge and should serve as a wake-up call for caregivers and relatives."  Based on a study last year, the article reports that statistics bear this out: "[s]ix months after visiting the ER, seniors were 14 percent more likely to have acquired a disability — an inability to independently bathe, dress, climb down a flight of stairs, shop, manage finances or carry a package, for instance — than older adults of the same age, with a similar illness, who didn’t end up in the ER."  This doesn't mean those who visited the ER were always admitted, and in fact, in many instances the converse was true.

The takeaway: Illnesses or injuries that lead to ER visits can initiate “a fairly vulnerable period of time for older persons” and “we should consider new initiatives to address patients’ care needs and challenges after such visits,” said one of the study’s co-authors, Dr. Thomas Gill, a professor of medicine (geriatrics), epidemiology and investigative medicine at Yale University.

The article notes that those needing help with ADLs or IADLs for example, are particularly at risk of having problems after an ER visit.

January 11, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Tuesday, January 9, 2018

MN Concerns SNF Penalty Rollback Affects Efforts to Fight Elder Abuse

We reported recently that the administration has decided to take a step back from the imposition of penalties vs. nursing homes.  The StarTribune ran a story that Minnesota officials have concerns that this step back will harm their efforts to fight elder abuse. U.S. easing of nursing home penalties could imperil Minnesota's crackdown on elder abuse notes that "[t]he federal move also comes as Gov. Mark Dayton has pledged tougher action against elder abuse and has promised improvements to the state’s troubled system for investigating and responding to allegations of maltreatment in senior homes." The article reminds readers of a five-part series that the paper had run back in November of 2017 that focused on the state's handling of elder abuse cases. The series was the catalyst for the Minnesota Governor's creation of "a working group to review state oversight of senior care homes and transferred some enforcement authority from the Health Department to the Department of Human Services, which has more resources." The state's acting Commissioner of health has taken steps to attack the backlog of those elder abuse cases pending investigation by increasing staff and moving away from paper records.   The article also offers some comments from those who support the step back from the use of penalties.

 

January 9, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (0)

MN Concerns SNF Penalty Rollback Affects Efforts to Fight Elder Abuse

We reported recently that the administration has decided to take a step back from the imposition of penalties vs. nursing homes.  The StarTribune ran a story that Minnesota officials have concerns that this step back will harm their efforts to fight elder abuse. U.S. easing of nursing home penalties could imperil Minnesota's crackdown on elder abuse notes that "[t]he federal move also comes as Gov. Mark Dayton has pledged tougher action against elder abuse and has promised improvements to the state’s troubled system for investigating and responding to allegations of maltreatment in senior homes." The article reminds readers of a five-part series that the paper had run back in November of 2017 that focused on the state's handling of elder abuse cases. The series was the catalyst for the Minnesota Governor's creation of "a working group to review state oversight of senior care homes and transferred some enforcement authority from the Health Department to the Department of Human Services, which has more resources." The state's acting Commissioner of health has taken steps to attack the backlog of those elder abuse cases pending investigation by increasing staff and moving away from paper records.   The article also offers some comments from those who support the step back from the use of penalties.

 

January 9, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (0)

Monday, January 8, 2018

Florida Nursing Homes and Emergency Generators

Here's an update on this issue in Florida.  The Florida legislature opens its 2018 session on January 9, 2018 and one of the issues on the legislative agenda is whether to legislatively require nursing homes to have generators and enough fuel to power them for a certain length of time during an emergency.  In addition, concerning the Florida administrative agency's proposed rules on requiring emergency generators (the Governor's emergency administrative order was struck by an ALJ): the ALJ has scheduled a hearing over three days (January 17, 19 and 24, 2018).

Although this issue Florida resulted from Hurricane Irma, it's worth watching.  Emergency generators can be important beyond just hurricane-prone states. Consider the recent winter storm Grayson that was described as a "bomb cyclone". The storm resulted in power outages for many, so it's not too far a stretch to recognize that emergency generators could come in handy beyond Florida. Stay warm!

January 8, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (1)

The Challenge of Finding Safe & Effective Pain-Killers for Older Adults

Over the holidays, unfortunately I had the experience of learning more about how older consumers struggle to understand what safe and effective treatments are available.  In this instance, my mother, in her 90s, was experiencing overwhelming back pain.   She has a long-history of osteoporosis (and it runs in the family on the female side, so my sister and I pay particular attention to this issue!) and in the last few weeks without any known "accident," she had begun to find it almost impossible to walk without pain.  She's not the complaining type, and, having been raised by parents who were Christian Scientists, she tends to follow a "mind over matter" approach to this kind of problem.  But, by Sunday last week, it was no longer possible to pretend she wasn't deeply uncomfortable.

We began another health care odyssey.  Some of the steps we had already learned from past "holiday" experiences with my parents, including calling the "non-emergency" 911 number to get an experienced EMT evaluation of her status in the home, and, if necessary, a transport from her home to the emergency room.  Then, recognizing that New Year's Eve is probably not the best night (if such a thing even exists) to spend in the local hospital's ER, we decided to go early in the morning.  

Five hours after our arrival in the ER, we left with a new "LSO" back brace, instructions on how to use it, and prescriptions for a different walker and a new pain medication.  On the latter point, we informed the ER physician of the fact Mom had not done well on narcotic pain relievers in the past ("why are those ants crawling on the walls") but we were told the drug prescribed was like a very strong Ibuprofen, but in a formulation that would not interact with the blood thinner she was on or her pacemaker.

We duly stopped at the pharmacy on the way home, and I signed my life away in order to pick up her prescription as she was unable to walk in to get it herself.  When we got home,  there were two documents in the bag with the prescription, including what I would call a typical "product insert" that looks like a page from the Physician's Desk Reference and a second sheet entitled "Directions for Use."  The top of the instructions warned, "This is a narcotic drug and not recommended for the relief of pain in...."  And then the list of disqualifying conditions included at least 3 of my mother's age-related conditions.  Yikes!  

My sister and I are  not usually intimidated by product inserts, but here the instructions seemed directly at odds with our concerns about narcotics for mom.  Everything we found on the internet only made us more confused and worried.  

By this time it was late on New Year's Eve, her pain was increasing, and we knew we couldn't persuade her to go back to the ER and her primary care physician wasn't on call.  The bottle said "every 6 hours."  The ER physician had orally told us "every 6 to 8 hours," and finally we knew we had no choice -- her pain was real and we started using it at 12 hour intervals, gradually moving down to 8 hour intervals before she seemed to have real relief.  It was another 5 days before her very kind primary care physician could squeeze us in for an appointment to have a more complete conversation -- and the good news is that we are now more comfortable about a longer range plan.

So on the heels of that multi-day experience, I was very interested in an article I spotted for my airplane trip home to Pennsylvania from Arizona. Phoenix Magazine had a detailed feature story in their January 2018 issue on "Pharma Chameleon," reporting on the arrest for fraud and racketeering charges of INSYS  Therapeutics founder, a "billionaire executive" in Phoenix, well-known for his work on painkiller medicines.  The history of this executive has nothing to do with my mother's pain relief medicine, but it was definitely a reminder that the pharmaceutical industry is deeply involved in pursuit of the "next" generation of painkillers.  And, of course, this article contrasts with the recent news that a different drug company is dropping R & D for a dementia drug.  Pain-killers are still "in," and dementia drugs apparently are "out."  

So, I recommend the Phoenix Magazine article!  I was particularly struck by this paragraph:    

In November, Kapoor [the Phoenix-based INSYS executive arrested by the feds] pleaded not guilty to all charges and is currently awaiting trial, along with the six other former executives, who pleaded not guilty last January. All have severed ties with INSYS, which continues to do business. In July, it received FDA approval for a new drug, Syndros, a synthetic form of THC, the psychoactive component found in cannabis, to treat chemotherapy-induced nausea and loss of appetite in AIDS patients. As it did with Subsys, the company is looking into ways to manufacture the drug as a sublingual spray. Under Kapoor, the company donated $500,000 to the effort to defeat the measure to legalize marijuana for recreational use on Arizona’s 2016 general election ballot, paving the way for the synthetic substitute.

January 8, 2018 in Consumer Information, Crimes, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science, State Cases, State Statutes/Regulations | Permalink | Comments (1)

Sunday, January 7, 2018

Pfizer Inc. Announces It Will End Research on Alzheimer's & Parkinson Drugs

According to the Wall Street Journal, Pfizer Inc released a public statement on Saturday, January 6, 2018, announcing the end of R & D for new drugs for treatment of Alzheimer's Disease and Parkinson's Disease.  The announcement reflected cost of efforts and the lack of success, and apparently the decision will mean layoffs for some 300 employees "over several months."

The Wall Street Journal also provided context for the disheartening decision:  

Like several peers, Pfizer has invested heavily in developing treatments for Alzheimer’s and Parkinson’s because of the huge need. About 5.5 million Americans have Alzheimer’s, and the numbers are expected to rise as the population ages. Analysts say successful treatments for the memory-robbing disease could have multibillion-dollar sales potential.

 

But promising compound have repeatedly failed to work during testing.

 

Notably, in 2012, Pfizer and partner Johnson & Johnsonhalted development of an Alzheimer’s drug called bapineuzumab after it failed to slow memory loss in test subjects.

 

The most recent disappointment took place last year, when a closely watched study of a treatment from Axovant Sciences Inc. called intepirdine failed to improve memory and learning in Alzheimer’s patients.

Companies that are still looking at possible Alzheimer's treatments include AstraZeneca, Biogen Inc, and Eli Lilly & Co., according to the WSJ article.  

January 7, 2018 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Science | Permalink | Comments (1)

Thursday, January 4, 2018

The Role of Social Supports in Preventing or Reducing Impact of Elder Abuse

The National Adult Protective Services Association National Committee for the Prevention of Elder Abuse have released a new Research to Practice brief, Social support can diminish negative effects of elder abuse.  

Here is an excerpt of the summary of the research

In general, compared to non-victims, victims of elder abuse reported higher rates of Major Depressive Disorder (MDD), Generalized Anxiety Dis-order (GAD), Post-Traumatic Stress Disorder (PTSD), and poorer self-reported health. Depression and PTSD in particular appeared to be most impacted by mistreatment. However, the level of perceived social support during the past month protected against the negative effects of mis-treatment, with the exception of PTSD outcomes. In particular, social support even seemed to undo the effects of mistreatment on GAD symptoms and self-reported health outcomes. This finding about the important protective effects of social support is especially meaningful and interesting, given that a current aspect of functioning (i.e., how much social support someone feels that they are receiving) seems to lessen the nega-tive impact of a past event that occurred many years prior.

 

 

 

January 4, 2018 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship | Permalink

Wednesday, January 3, 2018

Monetary Penalties vs. SNFs lessened

According to a recent story in Kaiser Health News, Trump Administration Relaxes Financial Penalties Against Nursing Homes, "[t]he ... administration — reversing guidelines put in place under President Barack Obama — is scaling back the use of fines against nursing homes that harm residents or place them in grave risk of injury." According to the article, the change was requested by the industry. Is the change needed? Judge for yourself:

Since 2013, nearly 6,500 nursing homes — 4 of every 10 — have been cited at least once for a serious violation, federal records show. Medicare has fined two-thirds of those homes. Common citations include failing to protect residents from avoidable accidents, neglect, mistreatment and bedsores.

The new guidelines discourage regulators from levying fines in some situations, even when they have resulted in a resident’s death. The guidelines will also probably result in lower fines for many facilities.

Both sides have weighed in on the appropriateness of the loosening of penalties, with opponents expressing concern about reducing deterrence. The changes have been gradually occurring over the fall. "In November, the ... administration exempted nursing homes that violate eight new safety rules from penalties for 18 months. Homes must still follow the rules, which are intended, among other things, to reduce the overuse of psychotropic drugs and to ensure that every home has adequate resources to assist residents with major psychological problems."  The New York Times also ran a story about the changes, which is available here.

January 3, 2018 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink